The ED in Population Health Utilization and Communication Hans - - PowerPoint PPT Presentation

The ED in Population Health

Utilization and Communication Hans Notenboom, MD Medical Director, S acred Heart Emergency Departments

 I have no relevant financial disclosures

Roadmap

 Hist ory  Recommendat ions  Current t ools  Examples

History

 New England Healt hcare Inst it ut e (NEHI) produces

“ Wast e and Inefficiency in t he Healt hcare S yst em”  Examines areas of waste  S

uggestions for improvement

 Launched initiative to improve waste

The Triple Aim

 Inst it ut e for Healt hcare Improvement (IHI)  Improving t he pat ient experience of care (qualit y and

sat isfact ion)

 Improving t he healt h of populat ions  Reducing t he per capit a cost of healt h care  Much of t his direct ly relat es t o t he NEHI st udy

NEHI S tudy

 30%

• f cost , or $700 billion in wast ed care

 Care that could be eliminated without reduction in quality

 S

ix maj or sources  Unexplained variation in clinical care  Patient medication adherence  Misuse of drugs and treatments  Emergency Department overuse ($38 Billion)  Underuse of appropriate medications  Overuse of antibiotics

ED Use Rising

 Many papers support t his, as well as our collect ive

experience  Past 15 years has almost doubled at our facility

 2000 –

50,000 visits per year

 2015 –

90,000 visits per year

 Why?  Is that good or bad?  What are the impacts?

Who and Why?

 “ S

uperusers” are 1%

• f ED patients but can account for 30%
• f

costs

 Insured actually responsible for much of the overuse  Limited access to primary care –

huge issue locally

 Convenience –

after hours and weekends

 Immediate reassurance of medical conditions  Primary care refers to ED  Hospitals have financial and legal obligations to treat all

patients

Best Option for Care?

 Fragment ed care in ED

 Lacks benefit of continuity of care

 Over ½ of Americans have a chronic condition  Disease prevention  Follow through of treatment plans

 Lack of care coordination

 Difficult for patients to understand discharge and aftercare

NEHI Recommendations

 Est ablish collaborat ive relat ionships bet ween EDs,

primary care, and communit y services

 Underst and t he pat ient populat ion  Reform payment for primary care services  Invest in Healt hcare Informat ion Technology (HIT)  Increase t he primary care workforce  Redesigning primary care services

Current Tools

 Emergency Depart ment Informat ion Exchange (EDIE)  Prescript ion Drug Monit oring Program

What is EDIE?

 EDIE is a web-based application developed to help Emergency Departments (EDs) identify high-utilization and complex needs patients who frequently visit EDs for their care, and who would be better served in a different care setting.

EDIE is…

 Collaborat ive framework for case management  Proact ive not ificat ion

 In the moment

 Coordinate on site  Bird in the hand

 Way t o share bet ween different organizat ions or groups

(i.e. ED doct ors, social services, primary care), regardless of IT plat form

EDIE isn’ t…

 Punit ive or way t o cat ch people  Full EMR  Full healt h informat ion exchange (HIE)

EDIE S uccess: Washington

 As part of t he “ ER is for Emergencies” init iat ive t o

reduce unnecessary ED visit s by Medicaid pat ient s, EDIE was implement ed in 91 hospit als in

Washingt on S t at e.

 11%

S t at e-wide Visit Reduct ion in

Medicaid patients with 5 or more annual ED visits

 58%

Visit Reduct ion in patients with Care

Guidelines

 $33 Million in S

avings for Washington S

tate

EDIE in Oregon is growing

 S

ummer of 2014, more t han 62%

• f hospit als act ive and

sharing informat ion

 All hospit als in Oregon signed at t est at ions wit h plans t o

be live by t he end of 2014.

S

• me Oregon details

 Oregon t racking t he ED visit s, high ut ilizers and 60 day

pat ient s  High utilizer is any patient that visits any ED 5 or more

times in a 12 month period

 60 day patients include anyone that visits 3 or more

different EDs in a 60 day period

 Informat ion is sent t o Oregon leaders and hospit al

leaders mont hly

 Breaks down by age, diagnosis and more

Most Recent S napshot

Regional Breakdowns

Example of Diagnosis Breakdown

Age Breakdown

Results starting to show in Oregon

S

• me local specifics

 S

pecific crit eria can be set for each inst it ut ion (# of visit s, et c.)

 Result s available wit hin 3-5 minut es of regist rat ion  Pushed t o ED as well as care management (can be

t ailored)

 Our crit eria:

 4 or more visits to the ED within 60 days  3 or more visits to any EDIE facility in 60 days

Care Planners – What Do They Do?



Find/ verify PCPs and other providers, counselors, etc.



Notifications letters to PCP , providers



Enter plans of care and expectations



Link pain/ medication contracts from outside sources



Education for proper use of ED / urgent care / PCP



Referrals for S DS , Medicaid, APS and community health workers



Coordinate in home health, transportation, hospice, equipment (O2)



Reminders for high risks (meds / conditions / behaviors / etc)



Assistance for coordination for people with no resources or ability (e.g. homeless with no phone)

Local S uccess

 59 yo woman  Hist ory of ICH, mult iple pain relat ed complaint s,

seizures, and more

 19 visit s in 2014  EDIE flagged and care management addressed  Coordinat ed wit h V

A, connect ed wit h care mgmt, and PCP

 No visit s since December

Local S uccess

 57 yo male  Poorly cont rolled DM, medicat ion non-compliance, pain,

and ment al healt h issues wit h depression and S I

 24 visit s in 2014 wit h mult iple admissions  Homeless and living in a t ent  Care planned and received medical respit e care and

coordinat ion

 1 visit since November 14

Local S uccess

 Quicker ident ificat ion  45 yo male wit h ETOH abuse and mult iple

hospit alizat ions

 7 ED visit s in 2 mont hs wit h a few inpat ient st ays  Care planning set up wit h fost er home, wit h parent al

coordinat ion.

 No visit s in past 3 mont hs since care coordinat ion

Future Opportunities

 Closer coordination with urgent cares and PCPs to get the

right patients, the right treatment, at the right times

 S

hared protocols through information exchange (e.g. EDIE) to impact outcomes and utilization  Reduce variability and stop the ‘ shopping for treatment’

 Telemedicine

 Augmented ‘ ask-a-nurse’  Reassurance and triage coordination

 Further advancements of technology

 Broader Health Information Exchange (HIE)

Questions? ?